Diabetic Retinopathy is the leading cause of blindness of adults aged 20-74 years, causing up to 14,000 new cases of blindness each year. 15.7 million Americans, or 8.2% of the adult population, have diabetes, with approximately one-third of these cases undiagnosed. Nearly half of these people will develop some form of detectable diabetic eye disease in their lifetime. Ominously, the incidence of the more common Type 2 diabetes (formerly known as non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes) is predicted to rise sharply within the next decade, farther increasing the number of Americans at risk for vision loss and blindness. These facts show that diabetic retinopathy is a very serious and pervasive health risk among the American populace. Fortunately, blindness caused by diabetic retinopathy can be successfully prevented, if detected early enough. Strict monitoring and control of blood sugar levels has been shown to delay onset and slow progression of diabetic eye disease. For those who have already developed diabetic retinopathy, laser coagulation treatment has been shown to significantly reduce the risk of blindness. The odds of successful treatment are higher when treatment is administered in the early stages of the disease, further increasing the importance of early detection.
There is no disagreement on the need for regular screening of the diabetic population, but studies indicate that many people at risk still do not get adequate screening for ocular complications of diabetes. One study found that 26% of younger-onset diabetics and 36% of older-onset diabetics had not had an ophthalmic exam, and that 7% of younger-onset and 11% of older-onset diabetics had either never had an eye exam, or had not visited an ophthalmologist within the previous two years. The lack of proper screening is even more severe among the population groups that are at greater risk, such as African Americans or Latinos; groups who are nearly two times more likely than non-Hispanic whites to get diabetes. Characteristics of groups less likely to get the recommended ophthalmic care include low education, low income, shorter duration of diabetes, less severe diabetic retinopathy, no history of ocular problems, inadequate or no health insurance, and youth. Minorities, non-English speakers, those not seeing a diabetes specialist, and non-insulin users are also less likely to get the recommended eye exams. Potential barriers to screening include cost, lack of time, lack of transportation, no insurance coverage for the eye exam, lack of access to a local eye care provider, lack of a referral from the treating physician, lack of awareness about the importance of screening, and lack of understanding of potential risks and benefits.
Telemedicine and TeleOpthalmology
Telemedicine is a method of providing medical care from a remote location electronically via telephone, Internet, satellite, or other electronic means. In a typical telemedicine application, a device known as a “telemedicine peripheral” is used to collect physiological data or images, which are transmitted to an expert at a remote site for analysis. The person who takes the data need not be highly skilled if the peripheral can be made simple enough to use. In some cases, the person using the telemedicine peripheral device may be the patient themselves, as evidenced by the growing market for home care telemedicine monitoring peripherals. Another popular application of telemedicine is a remote consultation facilitated by a videoconference between the patient and the medical caregiver.
Telemedicine has historically been touted as a solution to the problem of access to medical care. Telemedicine is a viable way of addressing the issues of remote location, lack of access to specialty providers, and managed care cost constraints. Telemedicine promises improved access to medical care to diverse groups of people ranging from astronauts and soldiers to rural families and inner city residents. The notion has been around for decades, but the enabling technology is relatively new. Growth has been rapid in the 1990s, but implementation is still low. Some of the barriers to widespread implementation include technical issues such as bandwidth and image compression, licensing issues, malpractice concerns, physician reluctance, confidentiality concerns, and reimbursement issues. The technological barriers are retreating quickly due to advances in the rapidly expanding field of telecommunications. Driven by increasing technological breakthroughs and the pressures of cost-containment, interest in resolving the legal, ethical and reimbursement issues telemedicine continues to build on both a national and local level. Several states have developed their own telemedicine pilot programs, and various branches of the federal government have made a significant investment in telemedicine research and development.
Patient acceptance of telemedicine has been reported under numerous studies to be consistently positive, with overall satisfaction as high as 98.3%. User satisfaction is also positive, eliminating another potential barrier to widespread use. Telemedicine is proving to be a cost-effective way to provide medical care, particularly when used for screening purposes. For example, the Navy determined in a recent study that installation of telemedicine systems on-board ships would be cost effective, saving unnecessary MEDEVACs costing several thousand dollars each. Overall, the outlook is positive for the future growth of telemedicine. Telemedicine has the potential to completely revolutionize the healthcare industry, restructuring nearly every aspect of twenty-first century medicine.
TeleOpthalmology seems particularly well suited to rapid screening for diabetic eye disease. Several studies indicate that non-mydriatic retinal imaging, including digital imaging, is a viable and effective way to screen for diabetic retinopathy. Problems with this method include false positives, which are rare, and poor image quality unsuitable for accurate diagnosis. These problems are not pervasive, and do not outweigh the advantages of this method of screening. The main cause of poor image quality is corneal opacity, which is a problem mainly for older patients. Such patients are far more likely to be under regular ophthalmic care, and are less likely to need this type of screening for this reason.
Currently, ophthalmology systems for telemedicine exist, but their usefulness has been restricted by their high cost, large size, and complexity of use. Even products touted as “hand held” include a tethered connection to a larger base unit (Nidek NM-100 is one such example). These products tend to be multi-functional and are intended for use by ophthalmologists, optometrists, or other highly skilled medical professionals. Their costs range from $12,500-$32,000 or more for complete instruments that are telemedicine-ready, to thousands of dollars for a simple video add-on that is useful only if the physician also possesses a compatible opthalmoscope. Physicians in poor or rural areas are not likely to have the space, funds, or skills necessary to make use of these devices. These instruments are less likely to appeal to other primary care providers as well.